Financial Policy

CANCELLATION OF APPOINTMENT TIME

Your appointment time has been reserved especially for you. If you do not show or cannot keep your appointment, please call at least 24 hours prior to your appointment time, or a fee of $50.00* will be charged to your account. For cosmetic appointments, if you do not show or cancel 48 hours prior to your appointment a fee of $100.00* will be charged to your account. You will be personally responsible for this charge. It is not covered by your insurance plan. Future appointments will not be scheduled until this fee is paid.

FINANCIAL POLICY

Payment for service is due in full at the time of service. We accept cash, personal checks, and credit cards. It is the patient’s responsibility to notify us immediately of any changes in their insurance coverage or carriers. The best way we can facilitate this is for you to bring your insurance card(s) with you to each visit. We apologize if this presents any inconvenience. Please understand that it is ultimately the patient’s responsibility for payment of services. If your insurance company or other benefits program (HMO, PPO, or managed care) does not cover the entire balance, you are responsible for the remaining amount; annual deductible, co-payment and coinsurance. It is the patient’s responsibility to bring a valid referral for each visit or you will be asked to reschedule your appointment or sign a waiver and pay privately for your visit. Payment is due within 30 days of being notified of the balance. If the balance is not paid within 30 days of notification, your account will be assessed with a $15.00* administrative fee monthly.

After a balance has reached 90 days past due, we will start the process to turn your account over to an outside collection agency for further action. The patient will be responsible for any charges incurred in such action.

Please be aware that some services provided may be determined as “non-covered” services under your policy. It is the patient’s responsibility to be aware of the individual policy restrictions and guidelines. Payment is due at the time of service, or within 30 days upon receipt of a statement from our office.

Medicare: Patients are responsible for meeting their annual deductible and paying the 20% co-insurance.

Note: If you have recently joined (or changed) to a Medicare HMO, please let our staff know so we can update your records and advise you if we are participating providers

Note: Dermatology Center of Rockland, P.C. will only file secondary insurance if you have Medicare. We can supply you with any information that you may need to file with your secondary insurance company for reimbursement.

If a check is returned to the office for any reason, the original check amount plus a $35.00* returned check fee must be received within 30 days from the date the check was returned to avoid further late fees or collection action.

Please be advised any patients requiring biopsies and/or cultures sent to an out of office Laboratory, will be billed separately from that facility. I authorize Dermatology Center of Rockland to release any medical/insurance information necessary to process the claim. I understand I will be responsible for any co-pay, coinsurance, deductible etc. that is owed to this facility.

Your signature below signifies that you understand our policies and your responsibility regarding charges incurred in this office.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.